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ETHICS IN THE ERA OF SUPERBUGS… Nicolette du Plessis Paediatric Infectious Diseases [email protected] UPdate 2016 & antimicrobial resistance
ETHICS IN THE ERA OF SUPERBUGS…
Nicolette du Plessis
Paediatric Infectious Diseases
UPdate 2016
& antimicrobial resistance
CDC: AMR to the US economy annually*
$20 billion in direct health care
$35 billion in lost productivity
UK government: death toll of AMR
300 million people 2050
financial loss $100 trillion**
*Centers for Disease Control and Prevention, 2013
** O’Neill, 2014
Life in the post-antibiotic era is going to suck…
Greatest single jump in average human lifespan
in the recorded history of medicine…
BUT after 80 years
antibiotic over-use
regulatory hostility
corporate indifference
“Post-antibiotic era”
Reality: minor scrapes and sore throats will
become life-threatening events
Drugs will eventually fail
Drugs are not magic bullets
Just stop-gap measures
….the industry’s obligation to be ethical…
…promises of specific benefits to consumers…
When you promise or claim that using an
antimicrobial product will protect health, are
there issues of right and wrong?
There certainly are…
Herman s. Ethics and personal care. Chemical reaction, GCI August 2009
Belmont report
Ethical principles:
1. Autonomy / Respect for persons
2. Beneficence
3. Justice
4. Non-maleficence…
APUA
The Alliance for the Prudent Use of Antibiotics
Dedicated to antimicrobial stewardship (AMS)
What ethical considerations are there in AMS?
The APUA Clinical Newsletter
Is a life in the future
worth less than a
life in the present?
J Antimicrob Chemother 2012
How do we fairly
allocate resources?
Ethical considerations in treating disease
Many current health strategies: saving a life now is more important than saving a life in the future
WHO Global Burden of Disease project discounted the value of future lives
Are we really making decisions that benefit the most people irrespective of when they live?
Healthcare resources should be used to maximises the health benefit for the largest number of people…
Wharam and Lazarou Parasites & Vectors 2013, 6:234
We cannot predict
state of future populations
unforeseen events (war or emerging diseases)
may make investments in the future worthless
Invest most of our resources now to eradicate
diseases, and therefore save countless future lives.
Even if attempts at eradication fails…
…can lead to large populations being relieved of
their burden of disease if only temporarily…
Multi-pronged strategy
Vaccine development
Improved diagnostics
Antibiotic resistance surveillance
Antimicrobial stewardship
APUA Clinical Newsletter Vol.30 No.1
Half of the world’s production of antibiotics
are still used in animal and fish farming, which
has created reservoirs for resistant bacteria and
exacerbates the problem further
How do we fairly allocate resources?
solidarity
liberty
privacy
reciprocity
fairness
the common good
AMR and Questions of Justice The global burden of infectious disease is distributed highly unevenly
low-income countries are disproportionately affected by AMR
high income countries bear a larger share of the response
Developing new drugs and technologies
Enhancing surveillance and reporting systems
Conducting research in areas not aligned with current national priorities
At the same time, a response to AMR will also require that we provide better
access to high-quality drugs, diagnostic tools and expert care.
Goldman, 2012; Rex, 2014; Drive, 2014
Some solutions…
…implementation of antibiotic stewardship in health care
facilities and the community; development of rapid,
point-of-care diagnostics; recruitment of academic and
industry partners to increase the pipeline of antibiotics,
vaccines, and alternative approaches; and international
collaboration for prevention, surveillance, and control of
antibiotic resistance.
Nathan and Cars, N Engl J Med 2014
Central ethical message here…
Distributive justice
Access: vulnerable populations are essential
Key interventions
Partnerships (Bills & Melinda Gates…)
Preventative measures (Vaccines…)
Rewards
Prioritization of medical use
Littmann J. The Ethical Significance of Antimicrobial Resistance. Public Health Ethics 2015;1–16.
Respect for persons
Protecting the autonomy of all people
Treating them with courtesy and respect
Allowing for informed consent
New concept
Informed consent for antibiotic prescription
Central ethical message here…
Beneficence
Maximizing benefits while minimizing risks
New concept
Only use antibiotics after careful consideration
the risks and the benefits
…in a fully immunized immune-competent child, antibiotics for an URTI/mild OM is NOT
needed…
Central ethical message here…
Justice
Ensure reasonable, non-exploitative and
well-considered management choices in
every patient
Central ethical message here…
